Vulvovaginitis in healthy women

Diagnostic performance of an automated microscopy and pH test for diagnosis of vaginitis

Vaginitis is a common gynecological problem, nevertheless, its clinical evaluation is often insufficient. This study evaluated the performance of an automated microscope for the diagnosis of vaginitis, by comparison of the investigated test results to a composite reference standard (CRS) of wet mount microscopy performed by a specialist in vulvovaginal disorders, and related laboratory tests. During this single-site cross-sectional prospective study, 226 women reporting vaginitis symptoms were recruited, of which 192 samples were found interpretable and were assessed by the automated microscopy system. Results showed sensitivity between 84.1% (95%CI: 73.67-90.86%) for Candida albicans and 90.9% (95%CI: 76.43-96.86%) for bacterial vaginosis and specificity between 65.9% (95%CI: 57.11-73.64%) for Candida albicans and 99.4% (95%CI: 96.89-99.90%) for cytolytic vaginosis. These findings demonstrate the marked potential of machine learning-based automated microscopy and an automated pH test of vaginal swabs as a basis for a computer-aided suggested diagnosis, for improving the first-line evaluation of five different types of infectious and non-infectious vaginal disorders (vaginal atrophy, bacterial vaginosis, Candida albicans vaginitis, cytolytic vaginosis, and aerobic vaginitis/desquamative inflammatory vaginitis). Using such a tool will hopefully lead to better treatment, decrease healthcare costs, and improve patients' quality of life.

Real-world effectiveness and tolerability of Zelesse cream® for treating vulvovaginitis in adult women: an observational, prospective study

Objective

To assess the efficacy, acceptability, and tolerability of a vaginal cream based on plant extracts for treating signs and symptoms of vulvovaginitis (VV) (Zelesse cream®), either as monotherapy (non-infectious VV) or adjuvant to antimicrobial therapy (infectious VV).

Methods

This prospective, observational, multicenter study included women who attended outpatient offices for VV. The severity of signs (vaginal discharge, erythema, and edema) and symptoms (pruritus, burning, and dysuria) was assessed before and after 15±5 days of daily treatment with Zelesse cream on a 4-point scale (18-point global score).

Results

The study included 58 women aged 43.0±13.2 years, including 42 who were treated with Zelesse cream only and 16 who used Zelesse cream as adjuvant to antimicrobial therapy. All participants showed significantly reduced scores and absolute prevalence of individual signs and symptoms in both groups. Similarly, the median signs/symptoms decreased by 4.0 and 8.0 points in women using Zelesse only and those using Zelesse plus antimicrobial therapy, respectively. This product was well tolerated and had high acceptability.

Conclusions

Zelesse cream relieves signs and symptoms of VV, either as monotherapy in non-infectious VV or as adjuvant to antimicrobial therapy in infectious VV. Future randomized, placebo-controlled trials with larger sample sizes are warranted.

Frequency of Coinfection on the Vaginal Wet Preparation in the Emergency Department

Introduction

Vaginal infections are common in the emergency department (ED) but the frequency of vaginal coinfections identified on wet preparation is unknown.

Methods

The study examined a data set of 75,000 ED patient encounters between April 18, 2014, and March 7, 2017, who had received testing for gonorrhea, chlamydia, or trichomonas or had received a urinalysis and urine culture during the ED encounter. From this data set we reviewed 16,484 patient encounters where a vaginal wet preparation was performed on women age 18 years and older. Findings from the vaginal wet preparation and ED discharge diagnoses were examined to evaluate the frequency of vaginal coinfections with vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis.

Results

Among the women who had wet preparations, 4,124 patient encounters (25.0%) had a diagnosis of bacterial vaginosis, 625 (3.8%) had a diagnosis of vulvovaginal candidiasis, and 1,802 (10.9%) were infected with Trichomonas vaginalis. Twenty encounters (0.1%) had a diagnosis of vulvovaginal candidiasis and trichomoniasis; 150 (0.9%), bacterial vaginosis and trichomoniasis; 136 (0.8%), vulvovaginal candidiasis and bacterial vaginosis; and 10 (0.1%), trichomoniasis, bacterial vaginosis, and vulvovaginal candidiasis. On vaginal wet preparation, the mean white blood cell count was 13.0 per high-power field. Clue cells were found in 6,988 wet preparations (42.4%); 1,065 wet preparations (6.5%) had yeast and 1,377 (8.4%) had T. vaginalis. T. vaginalis was identified in 2.5% (266/10,542) of urinalyses and 8.4% (406/4,821) of nucleic acid amplification tests.

Conclusions

Vaginal coinfections were uncommon among women receiving a vaginal wet preparation in the emergency department. The most common vaginal coinfection was bacterial vaginosis and trichomonas.

Acceptability, tolerability, and effects on symptoms and signs of vulvovaginitis of a non-soap, herbal-based intimate hygiene solution (Zelesse®)

OBJECTIVE

To evaluate the acceptability, tolerability, and effects on vulvovaginitis symptoms and signs of a non-soap, herbal-based intimate solution (Zelesse®).

METHODS

We conducted a prospective, observational, multicenter study including adult women with symptoms and signs of vulvovaginitis with various etiologies, including candidiasis, trichomoniasis, bacterial vaginosis, and atrophic and irritative vaginitis. The presence and intensity of signs (edema, erythema, vaginal discharge) and symptoms (pruritus) of vulvovaginitis were evaluated before and after 5-15 days of daily use of Zelesse® alone or as a coadjuvant in antimicrobial therapy. Variables following a normal distribution and categorical variables were analyzed using the Student t-test and chi-square or Fisher's exact test, respectively.

RESULTS

A total 137 women were enrolled in the study; 87 (63.5%) women received concomitant antimicrobials and 50 (36.5%) used Zelesse® only. Global symptom scores and frequency of patients with vulvovaginitis signs and symptoms, and their mean intensity, decreased after treatment in both patient groups. Vaginal pH and (in the Zelesse®-only group) vaginal flora remained unaltered. The product was safe, well tolerated, and highly accepted by patients.

CONCLUSIONS

Zelesse®, the non-soap herbal-based solution in this study, may represent a safe and effective option for symptomatic relief of vulvovaginitis.

Identification of Candida species isolated from vulvovaginitis using matrix assisted laser desorption ionization-time of flight mass spectrometry

Background and Purpose:

Vulvovaginal candidiasis (VVC) is a common problem in women. The purpose of this study was to identify Candida isolates by matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) from women with vulvovaginitis that were referred to Ghaem Hospital, Mashhad, Iran.

Materials and Methods:

This study was conducted on 65 clinical samples isolated from women that were referred to Ghaem Hospital. All specimens were identified using phenotyping techniques, such as microscopy and culture on Sabouraud dextrose agar and corn meal agar. In addition, all isolates were processed for MALDI-TOF MS identification.

Results:

Out of the 65 analyzed isolates, 61 (94%) samples were recognized by MALDI-TOF MS. However, the remaining four isolates (6%) had no reliable identification. According to the results, C. albicans (58.5%) was the most frequently isolated species, followed by C. tropicalis (16.9%), C. glabrata (7.7%), C. parapsilosis (7.7%), and guilliermondii (3.1%).

Conclusion:

As the findings indicated, MALDI TOF MS was successful in the identification of clinical Candida species. C. albicans was identified as the most common Candida species isolated from the women with VVC. Moreover, C. tropicalis was the most common species among the non-albicans Candida species.

Diagnostic Value of Vaginal Discharge, Wet Mount and Vaginal pH - An Update on the Basics of Gynecologic Infectiology

The majority of uncomplicated vulvovaginal complaints (e.g. bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis) can be detected with uncomplicated basic infectiological tests and can usually be treated effectively without requiring further diagnostic procedures. Tests include measurement of vaginal pH, preparation and assessment of wet mount slides prepared from vaginal or cervical discharge, and the correct clinical and microbiological classification of findings. In Germany, at least in recent years, this has not been sufficiently taught or practiced. As new regulations on specialist gynecologic training in Germany are currently being drawn up, this overview provides basic information on gynecologic infectiology and summarizes clinically relevant aspects of recent microbiological findings on the physiology and pathology of vaginal flora. The clinical signs and symptoms of aerobic vaginitis, the pathogenesis of which is still not completely understood, are also reviewed. Finally, the symptoms, indications and risk factors for pelvic inflammatory disease (PID) are presented. In contrast to the above-listed infections, PID requires immediate culture of the pathogen from samples (e.g. obtained by laparoscopy) with microbiological diagnostic procedures carried out by specialist laboratories. A schematic summary of all pathologies discussed here is presented.

Highly-cited estimates of the cumulative incidence and recurrence of vulvovaginal candidiasis are inadequately documented

BACKGROUND

Available literature concerning the epidemiologic or clinical features of vulvovaginal candidiasis commonly reports that: 75% of women will experience an episode of vulvovaginal candidiasis in their lifetimes, 50% of whom will experience at least a second episode, and 5-10% of all women will experience recurrent vulvovaginal candidiasis (≥4 episodes/1 year). In this debate we traced the three commonly cited statistics to their presumed origins.

DISCUSSION

It is apparent that these figures were inadequately documented and lacked supporting epidemiologic evidence. Population-based studies are needed to make reliable estimates of the lifetime risk of vulvovaginal candidiasis and the proportion of women who experience recurrent candidiasis.

SUMMARY

The extent to which vulvovaginal candidiasis is a source of population-level morbidity remains uncertain.

Clinical efficacy and health implications of inconsistency in different production batches of antimycotic drugs in a developing country

OBJECTIVE

This study aimed at evaluating the in vitro efficacy and health implications of inconsistencies in different production batches of antimycotic drugs.

MATERIALS AND METHODS

in vitro susceptibility profiles of 36 Candida spp. - C. albicans (19.4%), C. glabrata (30.6%), C. tropicalis (33.3%), and C. pseudotropicalis (16.7%) - obtained from human endocervical and high vaginal swabs (ECS/HVS) to two different batches (B1 and B2) of six antimycotic drugs (clotrimazole, doxycycline, iconazole, itraconazole, metronidazole and nystatin) was determined using modified agar well-diffusion method.

RESULTS

None of the Candida strains had entirely the same (100%) susceptibility / resistance profiles in both batches of corresponding antimycotic drugs; while, different multiple antifungal susceptibility (MAS) rates were also recorded in batches 1 and 2 for corresponding antifungals. Only 14.3%, 27.3%, 16.7-33.3%, and 8.3-25.0% of C. albicans, C. glabrata, C. pseudotropicalis, and C. tropicalis strains, respectively, had similar susceptibility/resistance profiles toward coressponding antifungal agents in both batches; while up to 57.1% of C. albicans, 45.5% of C. glabrata, 66.7% of C. pseudotropicalis, and 50.0% of C. tropicalis strains were susceptible to one batch of antifungals but resistant to corresponding antifungals in the second batch. As high as 71.4% (C. albicans), 73.0% (C. glabrata), 50.0% (C. pseudotropicalis), and 66.74% (C. tropicalis) strains had differences of ≥ 10.0 mm among corresponding antimycotic agents.

CONCLUSIONS

Candida strains exhibited different in vitro susceptibility / resistance patterns toward two batches of corresponding antimycotic agents, which has clinical implications on the efficacy of the drugs and treatment of patients. The findings of the present study will be of benefit in providing additional information in support of submission of drugs for registration to appropriate regulatory agencies.

Epidemiological phenotypic characteristics of vaginal yeasts at the Comoros

The aim of the prospective, descriptive survey conducted in Moroni, Comoros was to establish the distribution of vulvovaginal mycoses in pregnant and symptomatic women and to study the epidemiological characteristics of the yeast isolates. All isolated strains were epidemiologically evaluated by phenotypical methods. Three phenotypic epidemiological studies were performed by morphotyping methods (including the colour reaction according to Quindòs et al. and structural morphotypes as described by Soll), by determination of phospholipase and by chemosensitivity evaluation according to the Clinical and Laboratory Standards Institute approved standard. Out of 253 women, 108 were found positive for yeast culture (42.7%). Fungal identification results showed that 61.6% was Candida albicans and 28.6%C. sake (32/112). Candida sake was a frequent vaginal inhabitant.

Antifungal drugs and the risk of selected birth defects

OBJECTIVE

This study examined whether first-trimester antifungal drug use was associated with the risk of selected birth defects.

STUDY DESIGN

Subjects were participants in a case-control study, the National Birth Defects Prevention Study, with singleton deliveries from 1997 to 2003. Based on maternal interviews, first-trimester antifungal drug use was compared between 7047 cases with isolated defects and 4774 nonmalformed controls using unconditional logistic regression.

RESULTS

Risk was elevated for hypoplastic left heart syndrome (odds ratio, 2.30; 95% confidence interval, 1.04, 5.06) but not for other cardiovascular defects. An increased risk of 1.88 was observed for diaphragmatic hernia but was not statistically significant. Estimates approximated unity for neural tube defects, oral clefts, anorectal atresia, hypospadias, and craniosynostosis.

CONCLUSION

First-trimester antifungal drug exposure was not strongly associated with the risk of most birth defects, but further studies should examine the preliminary results of an association with hypoplastic left heart syndrome.

Detection of Candida species in vaginal samples in a clinical laboratory setting

OBJECTIVE

To present the detection rates of Candida species in vaginal samples from patients visiting physicians.

METHODS

The presence of C. albicans, C. glabrata, C. parapsilosis and C. tropicalis in 3978 vaginal swabs from patients in six US states was detected by PCR amplification.

RESULTS

Candida DNA was detected in 33.1% of the population studied. Of the 1316 positive samples, 80.2% contained C. albicans, 14.3% contained C. glabrata, 5.9% contained C. parapsilosis and 8.0% contained C. tropicalis. Comparing samples by patients' state of residence revealed an association with the detection of C. glabrata (p = 0.029). Comparing samples by patients' age revealed a decrease in the overall detection of Candida (p < 0.001) and C. albicans (p < 0.001), concomitant with an increase in the detection of C. glabrata (p < 0.001) and C. parapsilosis (p = 0.025).

CONCLUSIONS

These results provide geographic- and age-specific data on four Candida species associated with vaginitis.

Detection and identification of Candida species associated with Candida vaginitis by real-time PCR and pyrosequencing

Real-time polymerase chain reaction (PCR) is currently considered the most sensitive method to detect low abundance DNA of pathogens in clinical samples. Furthermore, obtaining DNA sequence is the 'gold standard' of precise molecular detection. Here we combine species-specific real-time PCR and pyrosequencing to rapidly amplify and sequence ribosomal DNA from Candida albicans, Candida glabrata, Candida parapsilosis, and Candida tropicalis, which are commonly associated with candida vaginitis (CV). A standard curve was developed from plasmids containing the target DNA for each of the Candida species. A minimum real-time PCR and pyrosequencing detection limit of 100 copies per reaction was achieved. The combined technique was applied to the identification of the four Candida species in DNA extracts from vaginal samples. The results from 231 samples were compared with conventional PCR methods of identification. The results of both methods agreed on all but two samples, which were determined by both methods to contain C. albicans, but real-time PCR and pyrosequencing identified a second species that went undetected by conventional PCR. This is the first application of real-time PCR and pyrosequencing to DNA from vaginal samples for identification of four Candida species associated with CV, without the need for time-consuming culture methods.

A clinical multicenter study comparing efficacy and tolerability of topical combination therapy with clotrimazole (CanestenR, two formats) with oral single dose fluconazole (DiflucanR) in vulvovaginal mycoses. Klinische Multizenterstudie zum Vergleich von Effizienz und Vertraglichkeit einer topischen Kombinationstherapie mit Clotrimazol (CanestenR, zwei Verabreichungsformen) mit einer oralen Einzeldosis Fluconazol (DiflucanR) bei Vulvovaginalmykosen

Two topical formats containing clotrimazole [500 mg single dose vaginal tablet (VT) or 10% single dose vaginal cream (VC) for intravaginal use] combined with additional clotrimazole cream for topical application to the vulval area (Canesten 1 Combi, Bayer AG, Leverkusen, Germany) were compared with oral fluconazole 150 mg single dose treatment of vulvovaginal mycosis (VVM) in a single-blind clinical study. The objective of the study was to demonstrate the equivalent efficacy of the clotrimazole combination therapies (VT + 1% cream and VC + 2% cream), and fluconazole 150 mg oral capsule (Diflucan 1, Pfizer Gmbh, Karlsruhe, Germany) in terms of overall response defined as clinical cure and mycological resolution. Overall, combination therapies containing either clotrimazole 500 mg VTs or clotrimazole 10% VC were as effective as a single dose fluconazole 150 mg oral tablet in treating VVM with rates for overall response being 66%, 61% and 60%, respectively, after 14 days. There were no significant differences in the time to onset of symptom relief in the clotrimazole 500 mg tablet group and clotrimazole 10% VC compared with fluconazole 150 mg oral capsules. Only 50% of 88 patients across treatment groups with mycological recurrence also experienced return of symptoms over the entire 8 week follow-up period. All treatments administered were safe and well-tolerated and the number of patients experiencing adverse events was low.

Making sense of self-conscious emotion: linking theory of mind and emotion in children with autism

Self-conscious emotions such as embarrassment and shame are associated with 2 aspects of theory of mind (ToM): (a) the ability to understand that behavior has social consequences in the eyes of others and (b) an understanding of social norms violations. The present study aimed to link ToM with the recognition of self-conscious emotion. Children with and without autism identified facial expressions conscious of self-conscious and non-self-conscious emotions from photographs. ToM was also measured. Children with autism performed more poorly than comparison children at identifying self-conscious emotions, though they did not differ in the recognition of non-self-conscious emotions. When ToM ability was statistically controlled, group differences in the recognition of self-conscious emotion disappeared. Discussion focused on the links between ToM and self-conscious emotion.

Structure and Generation Mechanism of a Novel Degradation Product Formed by Oxidatively Induced Coupling of Miconazole Nitrate with Butylated Hydroxytoluene in a Topical Ointment Studied by HPLC-ESI-MS and Organic Synthesis

In a petrolatum based topical ointment formulation containing miconazole nitrate (1) as the active ingredient and 2,6-di-t-butyl-4-methylphenol (BHT) as a vehicle antioxidant, an oxidatively induced coupling reaction between miconazole nitrate and BHT occurred to form a novel adduct 1-(3,5-di-tert-butyl-4-hydroxy-benzyl)-3-[2-(2,4-dichloro-benzyloxy)-2-(2,4-dichloro-phenyl)-ethyl]-3H-imidazol-1-ium nitrate (2). The structure of 2 was established using high-performance liquid chromatography coupled with electrospray ionization mass spectrometry and was confirmed by comparing with a synthesized reference compound. The reaction proceeded through a quinone methide intermediate from BHT. Two synthetic methods were established for preparing 2.

Prevalence of vaginal colonization by drug-resistant Candida species in college-age women with previous exposure to over-the-counter azole antifungals

We enrolled 382 college-age women in a cross-sectional survey to investigate the relationship between use of over-the-counter (OTC) azole-based antifungal drugs and vaginal colonization by drug-resistant Candida. This study showed no correlation (P=.506) between previous OTC exposure and colonization of drug-resistant Candida in vaginal flora. However, a small number of resistant Candida species isolates were obtained from women with a history of multiple exposures to OTC antifungals; given the widespread use of these products, this may be an emerging concern.

Menopause and the skin

Women live one-third of their lives in the post-menopausal state. Significant hormonal alterations occur at the time of menopause, leading to a range of physiological disorders affecting multiple organ systems in the body. The effects of menopause on the skin have been underresearched. Many skin changes occur at the time of menopause and the cutaneous effects of hormone replacement therapy are significant. Menopausal changes in hormones may alter the biomechanical properties of the skin and certain disorders are more common in menopausal women, such as lichen sclerosus, atrophic vulvovaginitis, flushing and dysaesthetic vulvodynia. Hair and oral changes may also be associated. As the average life expectancy increases, dermatologists need to be familiar with skin diseases affecting women in this age group.

Swelling-controlled release system for the vaginal delivery of miconazole

Miconazole nitrate, a fungicidal, is effective for the local treatment of vaginitis. The objective of this project was to develop a swelling-controlled release delivery system for miconazole. An aqueous solution of 15% w/w poly(vinyl alcohol) was mixed with a specific amount of miconazole powder. The resultant mixture was cross-linked by freeze-thawing. The effect of the number of freeze-thawing cycles was studied at four levels. The effect of the presence of PEG was studied by mixing different concentrations of two different PEG. The swelling at the end of 48 h was significantly higher (32%) for the batch that underwent four cycles. The swelling within the first 15 min for the batches containing PEG1000 was approximately 9%. However, the swelling for the batches containing PEG1450, at much lower concentration, within the same period was between 10 and 19%. The drug release profiles up to 108 h were independent of the number of freeze-thawing cycles. The cumulative percent miconazole released, in the absence of PEG, (two, four, six, eight cycles) at the end of 108 h was between 30 and 35%. The drug release was lower for the batches containing PEG1000, irrespective of the concentrations, compared with the batches containing PEG1450. A comparison of the value of diffusional exponent (n) indicates the predominance of a Fickian diffusion mechanism of release from the hydrogels.